July 9, 2026
The Interdisciplinary Ethics Panel Approach to Resolving Ethical Care Concerns in Post-Acute and Long-Term Care Settings
By Howard J. Finger, DO, FPALTC
How Clinical Ethics Care Concerns Are Addressed in PALTC Settings
Prior to 2024, there was little in the medical literature about how post-acute and long-term care (PALTC) facilities address ethical care challenges. Based on an online cross-sectional survey of PALTC providers, ethical conflicts over treatment decisions and the interpretation of advanced directives were frequent.1 Yet, half of the facilities lacked a clear-cut dispute resolution process. Few respondents used a clinical ethics consultant (CEC) for assistance, and two-thirds (primarily medical directors) rejected surrogate instructions, while 71% claimed to have managed family conflicts. An actionable policy was recommended to increase access to ethics services and support staff skill development, aimed at improving end-of-life (EOL) care experiences for patients, families, and staff.
A Novel Ethics Deliberative Process in a PALTC Setting
The interdisciplinary ethics panel (IEP) process was developed in 2016 to address ethical challenges posed by unrepresented nursing home (NH) residents lacking decisional capacity when EOL decisions needed to be made, causing moral distress among care teams. It was based upon an algorithm developed by the Bioethics Council of New York City (NYC) Health + Hospital, our nation’s largest municipal health system, under the guidance of the late Nancy N. Dubler, Esq., a luminary figure in the field of bioethics.2 As a practical means to address this ethical dilemma at Coler Rehabilitation and Nursing Care Center, a large public NH in NYC with many unrepresented NH residents, the IEP was initially tailored and successfully applied.
IEP Composition
Core IEP members include: (1) CEC or designated clinician with prior training and experience in clinical ethics; (2) attending physician/nurse practitioner; (3) unit nurse (usually head nurse); (4) unit social worker; and (5) dietician, if ethical concern is relevant to nutrition. Additional participants may include an associate director of nursing, the chief medical officer, and consultants such as psychiatry and palliative care. Other care team members, such as therapeutic recreation, speech therapy, and behavioral health, can participate as needed.
Based on its success with the unrepresented, the IEP approach was later expanded to address all clinical ethics care concerns at Coler and at Henry J. Carter Specialty Hospital and Nursing Facility, fitting in well with the existing interdisciplinary care team (IDT) process. It helped improve overall quality of care as evidenced by key quality metrics with significant reductions in non-beneficial medical treatment for those with life-limiting illnesses, in favor of a palliative approach, consistent with current EOL care best practices.3
Advantages of the IEP Approach
It is modeled after the IDT and patient-centered care concepts, the standards of care in PALTC settings. Because it relies on a core group, it is much easier to assemble than an entire ethics committee, avoiding scheduling conflicts and delays. As core members represent the IDT confronting the ethical care concern, they already know the case details, as opposed to a larger ethics committee, which lacks first-hand knowledge. Another key benefit is inclusion of the CEC, assuring decisions are in accordance with guiding ethical principles. It appears beneficial in relieving moral distress among IDT members, as indicated by a satisfaction survey that elicited a 96 percent favorable response.4
Acquiring a CEC
One approach is to seek an external, experienced CEC to avoid training someone from the clinical team; however, this can be costly. Another possibility is to share the services of an established CEC within your health system to offset the cost; however, availability must be considered, as on-site time allotment may be limited.
The more practical approach might be to seek a capable practitioner from within your facility, ideally with prior training and experience in clinical ethics. Clinicians to be considered should possess the knowledge, training, and experience in addressing cases found in PALTC settings, along with the interpersonal skills to foster IDT collaboration and engagement.
Ideal candidates might be the facility medical director, a trusted senior attending physician, or a physician with prior training in geriatrics and/or palliative care, but do not rule out other IDT members who may possess such attributes.
If you identify a good candidate but prefer that this clinician receive further training, the good news is that many educational programs offer foundational training in clinical ethics consultation. Several are available online, which provide clinicians with the skills necessary to apply core clinical ethics frameworks to resolve these challenges. By enrolling in online courses, the practitioner will not have to miss work time.
Although the cost of providing training must be considered, in reality it is less costly than hiring an external CEC. In addition, clinicians receiving such training can continue to perform their prior duties while performing a key additional function that will benefit clinical teams.
Case Study of the IEP in Action
An older man with end-stage COPD, who possesses decisional capacity but will not make EOL decisions, is referred to ethics due to declining health. In recent months, he lost 25 pounds and now weighs only 90 pounds. During his lengthy stay, he refused palliative measures and remains in full code status. Previously, his quality of life was much better, as he enjoyed chess, popular music, and classic movies. He now seldom leaves his room.
When questioned about his EOL care preferences, he refrains from making decisions, deferring to his sister, who also declines to make a decision without his guidance. The IDT is frustrated, not wanting him to suffer, knowing CPR would be futile. Moral distress among them is rampant.
The CEC initially held discussions with the IDT, which advised not pressuring him to decide, believing it would make him more resistant. The CEC and social worker then visited him, but instead of discussing EOL care preferences, they talked about other matters related to his perceived quality of life, along with his hobbies and interests. He was cognizant of his declining health, apprehensive that he would die soon, constantly thinking about it, and no longer interested in activities he used to enjoy.
They then called his sister, detailing their conversation, during which he acknowledged his declining health. She stated that in recent conversations, he had avoided the subject. The next day, his sister called, noting that she spoke to her brother, who discussed his EOL care preferences, which he wanted to be focused on maintaining his comfort and quality of life.
The next day, an IEP discussion was held, during which the resident requested that his care plan focus on maintaining his comfort and quality of life while avoiding burdensome treatments. He agreed to enrollment in the palliative care program, with MOLST orders for DNR, DNI, no tube feeding, no dialysis, and hospitalization only if pain or severe symptoms cannot otherwise be controlled.
IDT members were relieved of their moral distress, as these palliative measures maintained his comfort and quality of life in his final months. He remained actively engaged up until his final day, passing on in his sleep and avoiding burdensome treatments, as per his wishes.
This case illustrates how the four pillars of clinical ethics (see below) provided a framework for resolving the ethical care dilemma:
- Autonomy (Respect for the Individual)—The IEP process reaffirmed the resident’s decisional capacity, a prerequisite for the autonomy to make his own care decisions.
- Beneficence (Acting in the Best Interest)—The IEP process assured that beneficence was an integral part of his care plan to maintain his comfort and quality of life.
- Non-Maleficence (Do No Harm)—The IEP process assured that burdensome medical treatments were avoided.
- Justice (Fairness)—The IEP assured fairness in the decision-making process, providing access to palliative care services to maintain his comfort and quality of life.
References
1. Hoffman DN, Strand GR. ‘Sit down and thrash it out’: Opportunities for expanding ethics consultation during conflict resolution in long-term care. The New Bioethics 2024;30(2):152–162.
2. Shkolnik A, Botnick L, Cooper A, et al. Nancy Neveloff Dubler and communitarian ethics at NYC Health + Hospitals. J Clin Ethics 2025;36(4):315-322.
3. Finger HJ, Vinoo D. Advancing team care equity. A memory care unit in a large New York City public nursing home. Caring for the Ages 2024;25(5):4.
4. Finger HJ, Dury CA, Sansone GR, et al. An interdisciplinary ethics panel approach to end-of-life decision making for unbefriended nursing home residents. J Clin Ethics 2022;33(2):101-111.
Howard J. Finger is attending physician/clinical ethics consultant at Coler Rehabilitation & Nursing Care Center and at Henry J. Carter Specialty Hospital & Nursing Facility in New York City. Dr. Finger was named the 2025 Clinician of the Year by the Foundation for PALTC Medicine.